Lichen planopilaris

 

If you haven’t heard of lichen planopilaris, it’s probably because it’s not that prevalent. It is, however, thought to be a form of a skin condition that is more common, called lichen planus. 
 

What is lichen planopilaris?

Lichen planopilaris affects areas of skin where there is hair, most often the scalp. It affects the hair follicles, causing inflammation around them and destroying them, replacing them with scarring and causing permanent hair loss in the areas affected. Lichen planus, on the other hand, is a non-infectious itchy rash that develops on other parts of the body including the arms, legs, trunk, mouth and genitals (even the inside of the mouth and the nails can be affected).
 

Who is affected by lichen planopilaris?

 
We don’t know exactly how many people develop lichen planopilaris but experts believe it’s two to five times more common in women than in men, and that it mostly tends to affect Caucasians aged between 40 and 60 years old (i) – though it can affect any adult of any age. Lichen planus, on the other hand, is estimated to develop in about one in 5,000 people (ii).
 
Lichen planopilaris is often described as a type of scarring alopecia. In fact, according to Alopecia UK, it’s one of the most common causes of scarring hair loss of the scalp (iii). And if you develop lichen planopilaris, you have up to a 50 per cent chance of developing lichen planus somewhere on your body too (iv).
 

Types of lichen planopilaris    

 
There are three recognised forms of lichen planopilaris     :
 

1. Classic lichen planopilaris  also sometimes called follicular lichen planus):

Follicular lichen planus can cause intense itching, tingling, pain, tenderness or burning of the scalp – however some people with lichen planopilaris don’t experience any of these symptoms.
 
Other things you may notice include patches that can sometimes be red, thick, rough,  or scaly (hyperkeratosis) on your scalp, most notably on the crown and top of the scalp, though any part of the scalp can be affected.
 
Typically, the hairs in these inflamed areas are easily pulled out, and in areas where hairs have been destroyed and fallen out altogether, the scalp can look smooth and shiny. Lichen planopilaris tends to develop slowly in patches, but it can progress with small patches that combine to form larger patches. Some people experience a faster development, with many patches of hair loss developing over just a few months. Diffuse hair loss – as opposed to patchy hair loss – is a symptom but it’s less common than patchy hair loss.
 

2. Frontal fibrosing alopecia

 
This type of lichen planopilaris mostly affects post-menopausal women. It too causes inflammation of the hair follicle, but tends to affect the hair at the front of the scalp, causing the hair in this area to recede in a band-like pattern (though it can sometimes affect the sides of the scalp too). Those affected by frontal fibrosing alopecia can also lose patches of hair in their eyebrows, which can in time lead to a complete loss of their eyebrows, as well as some of their body hair.
 

3. Graham Little syndrome (also called Piccardi-Lasseur-Graham Little syndrome)

 
Graham Little syndrome causes patchy scalp hair loss much like classic lichen planopilaris. However, it also causes the development of bald patches in the armpits and pubic hair. It can be accompanied by a skin rash that feels bumpy and sometimes itchy on the trunk, arms and legs.
 
The good news is lichen planopilaris – like lichen planus – isn’t contagious, so you can’t catch it from or spread it to other people. In many cases lichen planopilaris eventually becomes inactive and doesn’t get any worse, but any hair loss the condition causes is usually permanent.
 

What causes lichen planopilaris?

 
Nobody knows what causes lichen planopilaris, but there are a few different theories on the subject. It’s generally not thought to be a hereditary condition, though according to the British Association of Dermatologists there may be certain genes that increase your risk of developing it (HLA DRB1*11 and HLA DQB1*03, for instance, are two genes that have been linked with lichen planopilaris (i)).
 
Many experts, meanwhile, believe lichen planopilaris is an autoimmune disease because it’s a result of immune cells called T-cells attacking the hair follicles (in autoimmune conditions the immune system attacks normal, healthy tissues – find out more in our article What are autoimmune conditions?). 
 
Scientists aren’t sure what triggers this autoimmune response, but some think certain drugs, viruses and contact with certain metals may play a part (iv):
 

• Drugs that may be involved include beta-blockers (typically used to combat high blood pressure), angiotensin-converting enzyme (ACE) inhibitors (also prescribed for high blood pressure) and some diuretics (medicines used to increase water excretion in the body)

• Viruses linked with lichen planopilaris include the hepatitis C virus, herpes simplex virus type 2, human papillomavirus and human immunodeficiency virus (HIV)

• Metals involved may include gold, mercury and cobalt

 
Experts from the Scarring Alopecia Foundation, however, suggest lichen planopilaris may not be a true autoimmune condition after all, since it doesn’t follow the normal inheritance pattern of other autoimmune disorders, and no autoantibodies have yet been discovered for it (v). Instead, they say, it’s probably an inflammatory process triggered by genetic or environmental factors.
 

What is the best treatment for lichen planopilaris?      

Doctors can diagnose lichen planopilaris by examining your scalp and skin, but the condition can only be confirmed if you have a skin biopsy where one or two small samples of your scalp skin are removed and sent to a laboratory for analysis.
 
There is no cure for lichen planopilaris, but there are treatments that aim to control the symptoms as well as save hair that hasn’t yet been affected – some of these may work for you while others may not:
 

Steroid treatments  

 
These include topical steroid lotions, creams, gels or mousses that are prescribed to relieve itching by reducing inflammation (this may also help reduce hair loss). As with all other topical steroids these preparations must be applied carefully and sparingly since they can cause skin thinning. Some people may also be offered a steroid injection, which can be more effective in small areas – though the injections can often be painful and can cause side effects including thinning or dimpling of the skin.
 
Steroid tablets can also be prescribed for lichen planopilaris and often reduce inflammation quickly in severe cases. But because taking corticosteroids in the long term is linked with a higher risk of several side effects – including weight gain, high blood pressure, diabetes and thinning bones – only short courses are usually recommended.
 

Calcineurin inhibitor creams and ointments   

 
These too can reduce inflammation but they don’t thin the skin like steroid creams. These aren’t licensed for treating lichen planopilaris, but some GPs and dermatologists may prescribe them for it.
 

Hydroxychloroquine  

 
Prescribed primarily to treat malaria, this comes in tablet form and is sometimes used to treat lichen planopilaris. Taken as a low dose, it can be slow to start working and you will usually have to take it for at least four to six months to see whether or not it’s effective. You may need regular eye tests if you take hydroxychloroquine, as it can damage eyesight in a very small number of people.
 

Immunosuppresants  

 
Medicines that suppress the immune system are also used to treat lichen planopilaris, including drugs called methotrexate, ciclosporin and azthioprine – though these all have potential side effects, so if you’re prescribed any of them you’ll need to be monitored closely by a doctor or specialist.
 
Other medicines sometimes used to treat lichen planopilaris include actitretin and isotretinoin, retinoid drugs that are prescribed for dermatological conditions such as severe acne (these are also associated with several side effects and should not be taken during pregnancy); and the antibiotic medicines tetracycline and doxycycline, both of which are used to treat acne too.
 
Some people, meanwhile, can have an operation to have areas of hair loss removed or reduced in size, but the operation isn’t available on the NHS and is only suitable for those whose lichen planopilaris has been inactive for a few years. Hair transplants can be another option for some, but again the procedure isn’t available on the NHS.
 

Lichen planopilaris alopecia support    

 
If you’ve lost hair to lichen planopilaris you may choose to disguise it by wearing a wig or a hairpiece. Some are available on the NHS with a consultant’s prescription, though you will usually have to contribute something to the cost. Wigs and hairpieces can, of course, be bought privately too.
 
According to the British Association of Dermatologists there are also other techniques you can use to camouflage hairless patches, including using powders, sprays and hair fibres that are matched to your hair colour (vi).
 
The British Hair & Nail Society, meanwhile, recommends giving up smoking if you’re a smoker with lichen planopiloris, as it claims smoking can interfere with the activity of medicines and impairs skin healing (vii).
 

Shampoo for lichen planopilaris

 
It may also be a good idea to use hair products that are gentle on your scalp – especially if having lichen planopilaris is making it feel sensitive – including formulas that are free from ingredients such as alcohol, fragrance, essential oils, parabens and other preservatives.      
 

What foods should be avoided with lichen planopilaris?    

 
There aren’t any foods you should avoid or eat more of, since none has been directly linked with lichen planopilaris. But you may want to make sure your diet is as healthy and nutritious as possible, which entails eating at least five portions of fruit and vegetables every day. This can give you all-round support and ensure you’re getting the nutrients your body (including your hair and scalp) needs to stay as healthy as possible.
 
Some natural supplements may also be worth considering. For instance, if you’re one of the many people who find it hard to eat healthily at all times – which, let’s face it, isn’t always easy – a good-quality multivitamin and mineral supplement may be just the thing you need to help you cover all your nutritional bases.
 
Find out about the variety of multivitamin supplements available by reading our guide to multivitamins and daily requirements. 
 

Supplements for lichen planopilaris

 

Turmeric

This well-known curry spice contains several compounds with reported medicinal properties, the most important of which is called curcumin. A potent antioxidant, curcumin has been shown in studies to have natural anti-inflammatory properties, which may be helpful if you have an inflammatory condition such as lichen planopilaris. To date, however, there has been a lack of research into the use of turmeric specifically as a treatment for lichen planopilaris – though some scientists suggest it may have potential as a treatment for some of the symptoms of the related condition oral lichen planus (viii).
 
You can get more curcumin by adding turmeric to your meals. However the doses of curcumin used in clinical trials tend to be much larger than the typical amounts you’d get in food, which is why taking a good-quality supplement may be the easiest way to reap the compound’s anti-inflammatory benefits.
 
Find out more by reading our article What are the health benefits of turmeric? 
 

PEA

Short for palmitoylethanolamide, PEA is a fatty acid produced naturally by the body and found in all cells, tissues and fluids including the brain. You can also get it in foods such as soya beans, peanuts, eggs, flaxseed and milk.
 
An endocannbinoid-like chemical that belongs to a family of fatty acid compounds called amides, PEA is often described as an alternative to CBD, as both substances are thought to have similar properties including the ability to reduce pain and inflammation. Researchers, however, suggest PEA is safer than CBD, since it has been studied more extensively and has a more robust safety profile (ix) with no known side effects (x). A review of 16 clinical trials and meta-analysis also confirms PEA has painkilling actions (xi).
 

Vitamin D

Important for your bones, teeth, muscles and immune system, vitamin D may also be a valuable nutrient for those with lichen planopilaris. Indeed, researchers have discovered people with lichen planopilaris are significantly more likely to be deficient or to have low levels of vitamin D than the rest of the general population (xii).
 
Of course, this only suggests there could be a link between lichen planopilaris and vitamin D deficiency, and researchers have yet to investigate whether taking vitamin D supplements might prevent or treat the condition. However, experts have discovered that vitamin D supplements may help treat the symptoms of oral lichen planus when taken alongside conventional treatments (xiii).
 
Unfortunately being low in vitamin D is common, including in the UK. As a result, health officials advise all adults and children over the age of one consider taking a daily 10mcg supplement of vitamin D, especially during the autumn and winter months (xiv).
 
The recommended supplement form of vitamin D is vitamin D3 or cholecalciferol, as it’s the natural form of vitamin D the body makes when it’s exposed to sunlight (indeed, sunlight is our main source of the nutrient, which explains why so many people may need a top-up during the colder time of year). Vitamin D3 supplements are available in tablet and capsule form, plus you can get them in veggie-friendly drops too. Most vitamin D3 supplements are made from the fat of lamb’s wool, however, which means they’re unsuitable for vegans. However vegan vitamin D3 supplements – sourced from lichen – are now available.
 

Need more information?

 
There’s lots more information about keeping your hair and scalp healthy in the hair health section of our pharmacy health library, including articles about hair loss in men and hair loss in women. 

 

References:
 

1. Available online: https://www.bad.org.uk/pils/lichen-planopiloris/

2. Available online: https://patient.info/skin-conditions/skin-rashes/lichen-planus

3. Available online: https://www.alopecia.org.uk/lichen-planopiloris-scarring-alopecia

4. Available online: https://www.ncbi.nlm.nih.gov/books/NBK470325/

5. Available online: https://scarringalopecia.org/about-scarring-alopecia/types/lichenplanopillaris/

6. Available online: https://www.skinhealthinfo.org.uk/wp-content/uploads/2018/11/Lichen-planopiloris-updated-May-2016-lay-reviewed-April-20166.pdf

7. Available online: https://bhns.org.uk/ccs_files/web_data/Hair conditions/Scarring/Lichen Planopiloris PIL.pdf

8. Kia SJ et al., Comparison of oral Nano-Curcumin with oral prednisolone on oral lichen planus: a randomized double-blinded clinical trial. BMC Complement Med Ther. 2020;20:328. Available online: https://bmccomplementmedtherapies.biomedcentral.com/articles/10.1186/s12906-020-03128-7

9. Clayton P et al., Palmitoylethanolamide: A Potential Alternative to Cannabidiol. J Diet Suppl. 2021 Nov;28:1-26. Available online: https://www.tandfonline.com/doi/full/10.1080/19390211.2021.2005733

10. Clayton P et al., Palmitoylethanolamide: A Natural Compound for Health Management. Int J Mol Sci. 2021 May;22(10):5305. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157570/

11. Gabrielsson L, Mattsson S, Fowler CJ. (2016 Oct). Palmitoylethanolamide for the treatment of pain: pharmacokinetics, safety and efficacy. Br J Clin Pharmacol. 82(4):932–942. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094513/

12. Ali S et al., Vitamin D deficiency among patients with lichen planopiloris or frontal fibrosing alopecia. Jaad Int. 2022 Sep;8:109-110. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9305337/

13. Saeed S et al., Vitamin D in the Treatment of Oral Lichen Planus: A Systematic Review. Biomedicines. 2022 Nov;17(11):2964. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9687323/

14. Available online: https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d

 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 

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